PREA AUDIT: AUDITOR S SUMMARY REPORT JUVENILE FACILITIES

Transcription

1 PREA AUDIT: AUDITOR S SUMMARY REPORT JUVENILE FACILITIES Name of Facility: Frances Walker Halfway House Physical Address: 5332 Riveredge Drive, Titusville, FL Date report submitted: September 9, 2014 Auditor information: Shirley L. Turner Address: 3199 Kings Bay Circle, Decatur, GA shirleyturner3199@comcast.net Telephone number: Date of facility visit: August 8 & 11, 2014 Facility Information Facility Mailing Address: Same as Physical Address Telephone Number: The Facility is: Military County Federal Private for profit Municipal State X Private not for profit Facility Type: Detention Correction X Other: Residential Name of PREA Compliance Manager: Wendy Whittington Title: Director Address: Wendy.Whittington@aspireHP.org Telephone Number: Agency Information Name of Agency: Aspire Health Partners Governing Authority or Parent Agency: NA Physical Address: 5151 Adanson Street, Orlando, FL Mailing Address: S a m e a s A b o v e Telephone Number: Agency Chief Executive Officer: Name: Dick Jacobs Title: CEO Telephone Address: Dick.Jacobs@aspireHP.org Number: Agency Wide PREA Coordinator Name: Joseph Nixon Title: Administrator DJJ Address: Joseph.Nixon@aspireHP.org Telephone Number:

2 AUDIT FINDINGS NARRATIVE: The Frances Walker Halfway House (FWHH) is located in Titusville, Florida and is operated by Aspire Health Partners through a contract with the Florida Department of Juvenile Justice (DJJ). It is a moderate risk residential treatment facility that serves female juvenile offenders between the ages of 13 and 18. The facility capacity is 30. Forty-two residents have been admitted to the facility in the past 12 months. The length of stay is six to nine months. The Frances Walker Halfway House provides comprehensive gender-specific programming focusing on substance abuse treatment which addresses and supports the developmental processes of the residents, using a cognitive behavior therapeutic approach. Forty-three staff members have been employed at the facility during the past year. Medical services are provided on-site by a full-time Registered Nurse and a full-time Licensed Practical Nurse. An Advanced Registered Nurse Practitioner visits the facility weekly. The contract physician is on-site at least weekly and a contract physician is on call to the facility. The mental health unit consists of onsite staff and includes the Clinical Manager; three Senior Counselors; Care Coordinator; and Transitional Care Coordinator. The mental health counseling areas include but are not limited to: substance abuse; anger and aggression; trauma/abuse; developing healthy peer relationships; selfesteem; mood management; criminal thinking/high risk behavior; and restoring the family system. The contract psychiatrist is on-site at least weekly and is available by phone. Education and related services are provided to the facility by two teachers, school counselor and the Education Director through the Brevard County School District. The education courses focus on English, Math, Science, Social Studies and one elective course. The elective course is generally used to provide additional reading assistance, if needed or for vocational training. In addition to addressing their substance abuse, mental health, medical, and education needs, the FWHH program addresses the transitional needs of each resident. Volunteers from the community provide a variety of learning experiences and activities for the residents that include Girl Scouting, learning to be a victim s advocate; spiritual services; guest speakers; specialized style and make-up services; and others. DESCRIPTION OF FACILITY CHARACTERISTICS: There are six buildings that encompass the program. The main building consists of administration and a housing unit. In the administration area, which is the front of the building, there is a foyer where visitors enter; Secretary s office; Director s office; and conference room. Adjacent to this part of the building is one of the dormitory areas which consists of offices; 11 rooms; bathroom; closet; and at the end of the building is a day room/common area. Across from the main building are the recreation/multi-purpose building and the school building. In close proximity is the clinical mod which contains the medical clinic; medication cart room; treatment staff offices; and two bathrooms. 2

3 There is an open dormitory building, the LIFE House (Living Independently for Empowerment), that has a bathroom and a laundry room. The LIFE House is where the resident will learn independent living skills in addition to having several rewards that come with the placement. Residents must be on a certain phase, complete an application, and interview for placement prior to being transferred to the LIFE House. Another building contains the kitchen; dining room; maintenance office; pantry; and attached to it is an area that contains clothing, accessories and other items used for designated and special activities. The meals for the residents are prepared and delivered by another Aspire Health Partners residential facility. Residents are provided a reasonable amount of privacy during showers within their housing units. The grounds of the facility provide space for various outside large muscle and other activities. SUMMARY OF AUDIT FINDINGS: The notifications of the on-site audit were posted in buildings of the facility prior to the site visit. Photographs were taken of the posted notices and the photographs were electronically sent to this Auditor, noting their locations. Telephone conversations were held with the Director who also serves as the Compliance Manager to review the PREA audit processes. The Pre-Audit Questionnaire, facility policies and supporting documentation were uploaded to a flash drive, which was received by the Auditor prior to the on-site audit. After reviewing the information, notes were sent to the Director to seek clarity of information and to note the additional documents needed. In response to the issues noted, additional information was provided and discussed during the site visit and corrective actions were taken to provide clarity and address the issues. The on-site audit was conducted over a two-day period, beginning Friday, August 8 and concluding Monday, August 11, An entrance meeting was held with the Director. After the meeting a comprehensive tour of the facility was conducted by the Director, accompanied by the DJJ Administrator for Aspire Health Partners. During the tour, staff members were observed to be providing direct supervision and actively engaged with the residents. Random staff, specialized staff and residents were interviewed during the on-site audit process. The interviews of both staff and residents revealed their knowledge of PREA and the related issues. The staff members interviewed were aware of the related policies, the facility s operational procedures and understood their duties and responsibilities regarding PREA compliance. The residents interviewed demonstrated their knowledge of what PREA means and how to report sexual assault and sexual harassment. At the conclusion of the audit, a summary of the findings were provided in a close-out meeting with the Director. Number of Standards Exceeded: 0 Number of Standards Met: 39 Number of Standards Not Met: 0 Number of Standards Not Applicable: 2 3

4 Standard Zero Tolerance of Sexual Abuse and Sexual Harassment. The Florence Walker Halfway House has a comprehensive document, Operating Procedure A29, which details how the facility will implement the zero-tolerance approach to preventing, detecting, and responding to sexual abuse. The Operating Procedure is aligned with the Florida Department of Juvenile Justice PREA Policy 1919 (FDJJ 1919). Operating Procedure A29 and FDJJ 1919 contain definitions of the prohibited behaviors and sanctions for those who participate in such behaviors. The Director of the facility has been identified as the PREA Compliance Manager. Standard Contract With Other Entities for the Confinement of Residents. Meets Standard (substantial compliance; complies in all material ways with the standard X Standard Not Applicable The facility does not contract with other agencies for the confinement of residents. Standard Supervision and Monitoring Operating Procedure A29 requires an annual assessment of the staffing plan. A review of documents showed a completed internal assessment of staffing completed by the DJJ Statewide PREA Coordinator. The staffing plan is in accordance with the current contract with DJJ. The facility and DJJ are cooperatively working together regarding staffing, through identifying and hiring additional staff, which will be in accordance with the standard. Hold- 4

5 over staff members are identified for the shifts and a call-in process is in place to provide for the staffing ratios prescribed in the standard. The Operating Procedure and practice provides for unannounced visits that are completed by the Director and the Aspire Health Partners to conduct unannounced rounds to deter sexual abuse. A review of documentation and staff interviews confirmed the unannounced rounds. Standard Limits to Cross Gender Viewing and Searches Operating Procedure A29 prohibits staff from searching a transgender or intersex resident to determine the resident s genital status. Operating Procedures A29 and E06 prohibit crossgender strip and cross-gender pat-down searches. The viewing of residents by opposite gender staff while they are showering, changing clothes, and performing bodily functions is not permitted, unless there are exigent circumstances. There have been no cross-gender pat-down, strip or body cavity searches of residents during this audit period. All staff interviewed said that the facility policy and practice are that crossgender searches are prohibited. The residents interviewed confirmed that no cross-gender searches occur. The Operating Procedure requires staff of the opposite sex to announce their presence when entering a housing area or area where girls may be showering, changing clothes or performing bodily functions. Interviews with residents confirm this practice. Training was provided to staff regarding the searches of transgender and intersex residents. Standard Residents With Disabilities and Residents Who are Limited English Proficient According to A29, the facility will not rely on resident interpreters, resident readers or any kind of resident assistance except when a delay in obtaining interpreter services would 5

6 jeopardize a resident s safety or an investigation. Based on a review of the Operating Procedure and other documentation and staff interviews, the facility provide residents with sign language services and other interpreting services. Standard Hiring and Promotion Decisions Operating Procedure A29 and other facility policies provide for background checks on all employees and a process that includes the elements of the standard and DJJ policies. According to policy, a review of documentation and interviews with staff, applicants and employees are asked about previous misconduct. Documentation showed and interviews with staff confirmed that prior to the hiring of an employee or contractor, background checks are conducted. Standard Upgrades to Facilities and Technology A camera system is used for monitoring activities along with direct supervision of staff. The system enables staff to observe activities in various areas on the campus. Twenty-five cameras are strategically placed inside buildings and outside. Radios are used for staff communications within and outside of the various buildings. Standard Evidence Protocol and Forensic Medical Examinations 6

7 According the Memorandum of Understanding with Sexual Assault Victim Services (SAVS), victim advocacy services will be provided. When requested, a qualified staff member from the agency will provide support services including accompanying the victim through the forensic medical examination process and investigatory interviews; crisis intervention; information and referrals; and emotional support. The provision of services to be provided was confirmed through a representative of the advocacy agency. Further review of documentation revealed that SAVS has a rape crisis center staffed with sexual assault nurse examiners. The facility s Operating Procedure and information from SAVS provide that forensic medical examinations will be provided at no cost to the victim. There has not been a need for a forensic medical examination during this audit period. According to FDJJ 1919, the facility is not responsible for conducting administrative or criminal investigations. The DJJ Office of the Inspector General (OIG) is responsible for conducting administrative investigations; the Florida Department of Children and Families (DCF) is responsible for conducting allegations of child abuse; and the local law enforcement agency, Brevard County Sheriff s Office, is responsible for conducting criminal investigations. Standard Policies to Ensure Referrals of Allegations for Investigations A29 and FDJJ 1919 identify the agencies that will conduct the criminal and administrative investigations. Both documents instruct the facility staff to cooperate with the investigations and provide that an administrative or criminal investigation is completed for all allegations of sexual abuse and sexual harassment. During the past 12 months, there was one allegation of sexual abuse or sexual harassment, alleging inappropriate touching. The contacts were made by facility staff to the investigative agencies. The notifications included the Brevard County Sheriff s Office, who investigated the case resulting in the case being closed. An investigation was also conducted by the Office of the Inspector General and the allegation was unsubstantiated. The policy regarding the referral of allegations of sexual abuse or sexual harassment for an investigation is available to the public on the DJJ website. Standard Employee Training 7

8 Operational Procedure A29 provides for the PREA training. The staff training is comprehensive of the key areas referenced in the standard. A review of the training documentation and interviews with staff confirm that the training is provided in accordance with the standard. Standard Volunteer and Contractor Training A29 states that all volunteers and contractors must be trained on their responsibilities under the Operational Procedure and FDJJ 1919 regarding sexual misconduct prevention, detection, and response and according to the Florida Administrative Code Rule 63-H. According to the A29, the training is based on the services provided. Receipt of the training is documented as confirmed through document review. Standard Resident Education Operational Procedure A29 requires that newly admitted residents and those that may transfer to the facility receive information about the facility s zero-tolerance policy and how to report incidents or suspicions of sexual abuse or sexual harassment. Residents receive comprehensive education regarding PREA and periodic refreshers through a review of the information. A signed acknowledgement statement by the resident of having received the training is maintained. PREA education will be provided through accessible formats for residents who are limited English proficient, deaf, visually impaired, or otherwise disabled. 8

9 Standard Specialized Training: Investigations FDJJ 1919 states that staff in the OIG will be trained on the related policies and procedures regarding the handling of sexual misconduct incidents and reports. Documentation from the Brevard County Sheriff s Office stated that their investigators receive advanced training in sex crimes, domestic violence, and interviews and interrogations, in addition to the law enforcement certification. Standard Specialized Training: Medical and Mental Health Care Policy A29 addresses this standard. Documentation shows that the medical and mental health staff members have completed on-line specialized training through the National Commission on Correctional Healthcare. The facility nurses do not conduct forensic medical examinations. Standard Screening for Risk of Victimization and Abusiveness Operational Procedure A29 contains a section that outlines the process of screening for risk of victimization and abusiveness and the information to be obtained. The Screening for Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) instrument is completed on each resident. Staff and resident interviews and a review of documentation confirmed that the screening is being conducted. 9

10 Standard Use of Screening Information The facility uses the information from the VSAB to assist in determining housing and other program assignments. Operational Procedure A29 prohibits placing gay, bisexual, transgender, or intersex residents into confinement based solely on such identification or status. Housing and program assignments require determinations on each transgender or intersex resident on a case by case basis. The facility prohibits considering gay, bisexual, transgender, or intersex identification or status as an indicator of likelihood of being sexually abusive. There have been no residents isolated in the last 12 months because she was at risk of sexual victimization. Standard Resident Reporting There are internal ways a resident may report allegations of sexual abuse; sexual harassment; retaliation for reporting; and staff neglect or other violation(s) that led to abuse. A resident may talk to any staff member; complete a grievance form and place it in the locked grievance box; complete a Hear My Voice form to request to speak to a specific counselor, the Director, Program Manager, or other administrative or treatment staff; the DJJ hotline numbers are available and accessible; and third parties may report allegations to the facility or use the hotline numbers. A dedicated phone is provided in the clinical mod, accessible to all residents, to call the rape crisis center hotline number to report sexual assault.. Standard Exhaustion of Administrative Remedies 10

11 The facility has an administrative procedure for dealing with resident grievances. Operational Procedure A29 and the resident handbook contain information regarding the grievance system. A locked box is posted in the main building accessible to the residents. The residents are directed to complete a grievance form and put it in the box where an administrative staff member checks the box daily. The resident is not required to use the informal process for any situation regarding sexual abuse. The grievance system has a level of appeal. According to A29, there is no time limit for a resident to submit a grievance regarding an allegation of sexual misconduct and the resident will not be referred to the staff member who is the subject of the complaint. There were no emergency grievances alleging substantial risk of imminent sexual abuse filed in the past 12 months. Standard Resident Access to Outside Confidential Support Services Operational Procedure A29 states that all of the residents shall have access to outside victim advocacy services. A Memorandum of Understanding has been obtained with the local rape crisis center through Sexual Assault Victim Services. The information about the services is explained to the resident during the intake process and it is accessible to the residents. A dedicated phone is provided in the Clinical Mod for the resident to call the rape crisis center hotline number, if needed. The facility also has a MOU with trained staff at another Aspire Health Partners facility to provide support services as they relate to child abuse. The services include but are not limited to crisis intervention; therapy; and education for staff and residents on preventing child abuse, including sexual assault. The Procedure and staff and resident interviews reveal that residents have confidential access to their attorney or other legal representative and access to their parents or legal guardians. Standard Third-Party Reporting 11

12 The facility provides methods for third-party reporting of sexual abuse. The Parental Reference Guide is provided to parents and legal guardians of residents regarding reporting sexual abuse. A Handbook is provided to community board members that contain information on reporting sexual abuse. Posters and brochures are located in areas of the facility accessible to the public. Employees, volunteers and contractors sign an acknowledgement form stating their awareness of the PREA policies and the form provides hotline numbers for reporting sexual abuse. PREA information is available on the facility s website and there is a link to the DJJ website regarding the reporting of sexual abuse or sexual harassment on behalf of a resident. Policy Operational Procedure A29 provides for third party assistance to a resident in filing a grievance alleging sexual abuse. Standard Staff and Agency Reporting Duties Operational Procedure A29 and the Florida Administrative Code Rule 63F-11 address this standard. All staff members are required to report any allegation of sexual misconduct or resident-on-resident sexual activity to the Central Communications Center (CCC). The Procedure states that staff members are prohibited from revealing any related information to anyone other than those who are involved in treatment, investigation and other security and management decisions. Policy and procedures require that staff members are to immediately report any knowledge, suspicion or information they receive regarding sexual misconduct; retaliation against residents or staff who report any incidents; any staff neglect or violation of responsibilities that may have contributed to an incident or retaliation. Standard Agency Protection Duties According to A29, when staff learns that a resident is subject to substantial risk of imminent sexual abuse, immediate action must be taken to protect the resident. The facility reports that there have been no incidents in the last 12 months where the facility took any action in regards to a resident being in substantial risk of imminent sexual abuse. 12

13 Standard Reporting to Other Confinement Facilities According to A29, upon receiving an allegation that a resident was sexually abused while confined in another facility, the Director will notify the head of that facility or the appropriate office as soon as possible but no later than 72 hours after receiving the allegation. The Operational Procedure and FDJJ 1919 require notifying the appropriate investigative agency of all allegations of sexual abuse. In the past 12 months, there have not been any allegations of sexual abuse occurring to a resident while she was in another facility. Standard Staff First Responder Duties The staff first responder duties are incorporated in Operational Procedure A29 and are aligned with the requirements of FDJJ A29 outlines the first responder duties and other staff responses. Staff interviews confirmed that they are knowledgeable of their duties as a first responder. Standard Coordinated Response The coordinated response is incorporated in the facility s PREA Operational Procedure and is aligned with FDJJ Interviews with staff revealed that they are familiar with the institutional plan. The plan coordinates the actions to be taken among facility first responders and other staff in response to an incident of sexual abuse. 13

14 Standard Preservation of Ability to Protect Residents from Contact with Abusers Meets Standard (substantial compliance; complies in all material ways with the standard X Standard Not Applicable This standard is not applicable. The facility does not maintain any collective bargaining agreements. Standard Agency Protection Against Retaliation Operational Procedure A29 addresses this standard and identifies the PREA Compliance Manager as the staff member responsible for monitoring for retaliation against residents and staff members who report sexual abuse or sexual harassment. FDJJ 1919 and facility procedure require that if the retaliation conduct is identified, the monitoring would be conducted for no less than 90 days. There have been no incidents of retaliation reported in the past 12 months. While no incident of retaliation occurred, a review of documentation and interviews reveal that precautions were taken to prevent the occurrence of retaliation regarding the allegation of sexual abuse/harassment prior to the unsubstantiated findings of the investigation. Standard Post Allegation Protective Custody Segregated housing or isolation is not used. However, measures are taken to separate residents for their safety by changing their assigned room or building or providing a single 14

15 room placement and keeping the residents separated to the extent possible by staff. Documentation shows that during the investigation of the allegation of sexual abuse one resident was moved from the general housing building to the LIFE House while the other resident was housed in a room by herself until it was determined that the resident felt safe from possible retaliation. When this occurred there was no disruption to the program requirements. According to Operational Procedure A29, the Director/designee may coordinate the re-location of a resident if it is determined to improve the safety of others or the integrity of an investigation. Standard Criminal and Administrative Agency Investigations A29 and FDJJ 1919 provide direction for this standard. Administrative investigations are conducted by the DJJ Office of Inspector General (OIG) and criminal investigations are conducted by the local law enforcement agency. The Florida Department of Children and Families are also called when there is an allegation of sexual abuse and they may conduct investigations. The policy and procedures direct staff to cooperate with the investigations. Standard Evidentiary Standards for Administrative Investigations The OIG, responsible for administrative investigations, imposes a standard of a preponderance of the evidence for determining whether allegations are substantiated. Standard Reporting to Residents 15

16 FDJJ 1919 allows for the victim to be informed that the investigation has been concluded. At the conclusion of an OIG investigation, the victim or the victim s parents or legal guardian will be notified. At the conclusion of the investigations of the allegation that occurred at the facility during this audit period, the resident was notified that the allegation was unsubstantiated. Standard Disciplinary Sanctions for Staff Procedure A29 provides for disciplinary sanctions for staff to be up to and including dismissal for violation of the facility s zero-tolerance policy against sexual abuse and sexual harassment. It states that the presumptive disciplinary sanction for staff who engages in sexual abuse will be termination. In the past 12 months, no staff has been terminated or has resigned for violating the facility s PREA related policies. Standard Corrective Action for Contractors and Volunteers A29 and FDJJ 1919 state that any contractor or volunteer engaging in sexual abuse of residents will be subject to referral to local law enforcement regarding criminal charges and to relevant licensing bodies. FDJJ 1919 requires that the contractor or volunteer is prohibited from having contact with residents. During the past 12 months, no contractor or volunteer has been reported to law enforcement or any investigative agency for allegations of sexual abuse. Standard Disciplinary Sanctions for Residents 16

17 Operating Procedures A29 and E21 address this standard. Residents found in violation of the facility s zero tolerance policy regarding sexual abuse, sexual assault, sexual misconduct or sexual harassment against another resident will receive disciplinary sanctions after a formal disciplinary process. The sanctions or consequences are provided in the resident handbook and do not include isolation. The staff will complete a Change Behavior Report after an incident. There have been no criminal or administrative findings of sexual abuse in the last 12 months. Standard Medical and Mental Health Screenings; History of Sexual Abuse Operating Procedure A29 provides that residents who disclose prior sexual victimization or who disclose previously perpetrating sexual abuse during an intake screening will be offered a follow-up meeting with a medical or mental health practitioner within 14 days of the intake screening. It also requires informed consent from residents 18 years of age and older before reporting information about prior sexual victimization that did not occur at the facility. Staff interviewed confirmed awareness of the policy and procedure. Standard Access to Emergency Medical and Mental Health Services The Operating Procedure requires that treatment services to every victim will be provided at no cost to the victim. It also states that access to the services will be timely and unimpeded and based on the professional judgment of the medical and mental health staff. Interviews with staff confirmed their knowledge of the procedure. 17

18 Standard Ongoing Medical and Mental Health Care for Sexual Abuse Victims and Abusers A29 addresses ongoing medical and mental health care for sexual abuse victims and abusers. It also provides for the appropriate tests to be provided and that the facility will attempt to obtain a mental health evaluation within 60 days of learning of resident-on-resident abusers and offer treatment deemed appropriate by a mental health practitioner. Interviews with staff confirmed their knowledge of the information. Standard Sexual Abuse Incident Reviews Operating Procedure A29 and FDJJ 1919 states that the sexual abuse incident review team will include the PREA Compliance Manager, other upper-level management staff, Department staff, and allow for input from line supervisors, investigators, and medical and mental health staff. Interviews with staff revealed that the incident review process is in place. Standard Data collection FDJJ 1919 and interviews with staff confirmed that DJJ collects incident-based, uniform and aggregated data regarding allegations of sexual abuse at facilities under its direct control using a standardized instrument and set of definitions. Policy requires the collection of accurate, uniform data for every allegation of sexual assault. The agency provides DOJ with data as requested. 18

19 Standard Data Review for Corrective Action FDJJ 1919 addresses this standard. The statewide PREA Coordinator will review the collected and aggregated data to assess and improve the effectiveness of the PREA related efforts and initiatives. The Policy also states that an annual report will be prepared. A review of documentation confirms this practice. Standard Data Storage, Publication and Destruction According FDJJ 1919, it is required that data is collected and securely retained for 10 years. The aggregated PREA data is reviewed and all personal identifiers are removed. A review of documentation confirmed the practice. AUDITOR CERTIFICATION: The auditor certifies that the contents of the report are accurate to the best of her knowledge and no conflict of interest exists with respect to her ability to conduct an audit of the agency under review. September 9, 2014 Auditor Signature Date 19